Help please!!! Multiple Hernia and small bowel repairs


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So this case has me in a pickle. Any help is greatly appreciated. The following is the operative report:

Preoperative Diagnosis: abdominal pain

Postoperative Diagnoses: Multiple adhesions, internal hernia created by small bowel adhesions.

Procedures: Diagnostic laparoscopy, lyisis of adhesions, multiple small bowel repairs, closure of internal hernia.

Summary of Procedure: The patient was taken to the opertaing room, placed supine on the operating table, prepped and draped in the usual sterile fashion. After adequate general endotracheal anesthesia had been obtained, a blunt trip trocar was placed in the right lower quadrant through a previous incision. The abdomen was insufflated to proper pressure. The patient had some murky peritoneal fluid in the abdomen. This was aspirated and cultured. The patient had multiple areas of both small bowel and omentum adherent to the mass. These were carefully taken down. Running the small bowel, no injuries were seen, however, small bowel to small bowel adhesions had caused multiple interloop internal hernias, 2 were taken down, both instances with small bowel serosa, and muscle was injured and was closed with a figure of eight Vicryl suture. The 2 areas that had much larger areas of the small bowel to small bowel adhesions actually just had the mesenteric defects closed with Medtronic clips, as I think taken these down would have caused too much bowel injury that cannot be simply closed and did not appear to be an obstructing type adhesion, however, did run the risk of significant internal hernia. These were closed with Metronic clips. The abdomen was irrigated and aspirated. The anterior abdominal wall was closed with a # 1 Vicryl endo-close.

Please lead me in the right direction. For the internal hernia I'm thinking unlisted code 49659, for the initial small bowel repair 44202, 44203 for any additional small bowel repairs. Some of my other confusion arises when my doc states that 2 internal hernias were taken down. Does this mean we bill for 2 49659's? Or, is the use of modifier 22 more appropriate. Thank you so much!


Las Vegas, NV
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There are no mentions of resections or anastomosis of the small bowls to code 44202 and 44203. All I see a take down of adhesion lap procedure 44180 24 rvu….That includes any enterotomies that was made during the take down of adhesion within the small bowl…as far as the verbiage of internal hernia, I think that is just his/her way of describing it, looped up and all. Hope that shines a new light on things